That you think this is a trivial problem shows that you’re largely ignorant of some 30 years of research and clinical debate.
no but an mri scan and blood tests are pretty damned close
30 years of research and clinical debate have largely come to the wrong conclusion because medical doctors are, by and large, mathematically illiterate; in some countries, like the usa, they are also strongly motivated by cya, which comes into direct conflict with the patient's well-being in cases like this
if they don't you shouldn't
so either you're better off or you're no worse off
unless you have to be dealing with a doctor in cya mode
It'll also reveal a bunch of stuff you didn't need to know. Do you want to know about that minor slipped disc in your back that wasn't bothering you before? The nocebo effect is very real.
this superstitious ideology that ignorance is good for you has always been popular; what's surprising is that some people still hold to it despite the industrial and scientific revolutions
knowing about the minor slipped disc in your back might be important information if it starts hurting; you'll know it isn't a metastatic bone cancer. you might also be well advised to avoid taking up olympic weightlifting
How do you make that call? What do you, as an eager but uneducated layman, use to decide that? You now know there's a heterogeneous cyst in your abdomen that the doctor says is super unlikely to be cancerous but it's not impossible that it could be. How do you evaluate your odds? Are you opting for the biopsy? If there's a dozen of such cysts in all corners of your body? Again, the MRI is a tool to help spot a problem, it's not going to give you the diagnosis.
That's up to the individual to decide - blanketing people in ignorance and leaving it up to chance should not be the only option.
How are we supposed to ever make progress here if that's your mindset? This is the medical system that fears its own incompetence so much that it would prefer to NOT have data. How silly is that? What other industry operates this way?
this takes a little longer than undergoing the biopsy, but it's enormously more pleasant, and it lets you know when doctors are ignorant or lying, which is perhaps even more important information. it's orders of magnitude easier than undergoing chemo and radiation so i don't know why 'eager but uneducated' laypeople don't always do it. maybe they're too used to living in a world without sci-hub and libgen
it's also easier when it's not the first time
it's never impossible that any part of your body could be cancerous, so 'super unlikely to be cancerous but it's not impossible that it could be' is a terrible justification for taking action
If you knew that you or your spouse had something that could be an issue but was unlikely to be - and it's nearly guaranteed that somewhere in your body right now you have stuff that would come back as "possibly a problem" in imaging - you'd be comfortable not taking action? I doubt that's how most people would response.
i'm not here to protect most people from the consequences of their own bad decisions
Is this a trick question? I use my doctor's expertise and advice, obviously. Just like I do for any other nontrivial medical question.
This has happened to me a number of times throughout my life. I have some problem, my doctor requests a scan (or x-ray or ultrasound or...), it turns up some anomalies, and my doctor has to evaluate them to decide if they are relevant to anything. For many of them the answer is, no, they're not. Now I know that I have a cyst here and some slightly misaligned vertebræ there and ... that's fine. They weren't causing the problem I had and they're probably not causing any other problems either.
The argument that we must not look at ourselves because if we do, we'll be compelled by some mysterious force to take dangerous interventions is silly and just seems like an excuse for medical incompetence or laziness.
This is actually a bit subtle. For example I've heard more than one radiologist claim that if you look carefully, literally anyone's body scan will contain details that could justify work up.
The fact is, if you do this broadly in a population and you work up everything you see that would justify it, some small number of people will die or suffer serious problems from complications of follow up.
This is a fundamental problem in screening technologies (of any kind) with imperfect sensitivity. You can't get away from this, so you try and be clear that the net benefit is (much) higher.
I'm not even against the idea of baseline scans, but the idea that this part is simple is naive.
I'm no radiologist but I've seen enough of this done that I'd lean that way. Especially if you consider realistic bounds on time and additional information.
Think about say a diagnostic blood test with a poor sensitivity (but better than chance) on a very rare disease. As an oversimplification: for a bound take your population * workup rate * fatality rate due to workup and you have a baseline needless death due to the screening (NB there is basically always a fatality rate). The number you are comparing to is lives saved due to earlier detection.
Better than chance means it's strictly more information always. But as policy, you shouldn't do it unless you can be extremely confident that lives saves is much larger than lives lost due to the process.
This is a bit counter intuitive, but it is a fundamental issue in a lot of healthcare policy. The real calculations are more complex but in the end it is unavoidably actuarial in nature.
this is not a global optimization problem; it's a local optimization problem. one person is deciding whether or not to spend their own money on an mri, or a blood test or whatever, on themself. they are the ones in the best position to do that, and for very-low-risk tests like mris it is very rare that the optimal decision is for a rich person not to get them
Ignoring the fact that in the real world due to constraints this isn't really a local optimization, if we assume infinite availability you still have a problem that low sensitivity tests lead to excess unnecessary work up risks. Your assertion that it is always easy to get good information leading to correct choices here is just incorrect and probably naive.
The trade offs you are talking about are very well known and have been studied by professionals for decades; none of them will claim it easy - for good reasons.
Note I'm not appealing to authority here. Many people can educate themselves to the degree that in a narrow area of their own healthcare they are as or more knowledgable than the average professional. However, this is not at all easy, and will require a ton of work. The cost benefit for a lot of screening etc. just isn't there; for a particularly symptomatic disease it may well be.
This isn’t a controversial claim at all among people familiar with stats on outcomes across large populations. It’s tricky to get right and your glib dismissal comes across as arrogant and ignorant.
How do you propose the medical field determines which small tumors will become life threatening in general? Can you beat the best research hospitals in this task? Even an average oncologist?
you can calculate the cost and expected morbidity due to any particular candidate test (mri, blood panel, biopsy, ct, pet, whatever) and compare it against the reduced expected morbidity due to the probably-not-present disease, using whatever metric of morbidity you like best (ypll, daly, expected change in your malpractice insurance premiums, whatever), using whatever risk tolerance you like best. for mris and blood panels obviously this will favor doing the test in almost all cases, unless traveling to the hospital is a significant hardship or the money is enough to be important to you
for other tests it may not, and watchful waiting is often a better choice than doing further tests
with a little work, you can always beat the best research hospitals at this task because you care about different things than they do. this is not the same thing as beating them at guessing whether your prostate is going to kill you before something else does
Colonoscopies are a great example. As their use increases past a threshold more people are injured by additional surgery than you actually help. This is again at a population level.
There's no free lunch here.
Then wouldn’t these be left alone ?
The more research and procedures done the more info gathered on the evidence
At a population level its well established that beyond a certain point you're injuring more people than you are helping by doing the colonoscopies at all. Where to draw that line is where the debate is playing out. The problem is well known, and I'm not aware of ANYONE seriously suggesting that it's possible to eliminate this problem.
The problem is that you don't know which ones would never develop into anything if left alone.
The reason they're left alone now is that you don't know they're there, because you never do any test that shows them being there.
But once you do a test that shows that something is there, it's a lot harder to just leave it alone. Something is there, and you don't know that it's never going to be a problem, so you end up not leaving it alone.
If you were going to leave the thing alone anyway regardless of what the first test showed, there's no point in doing the first test at all.
Risk will dramatically decrease with advances.
> That you think this is a trivial problem shows that you’re largely ignorant of some 30 years of research and clinical debate.
Biologists are still doing punch card-level stuff. If we started cloning monoclonal, antigen-free bodies in massive body farms and performing head transplants, that'd solve almost every non-cranial disease. I could see that becoming a preventative solution to aging, too. Renewed cardiovascular health, clean lungs, thymus, etc.
This isn't a step function difficult thing to do [1-3]. Nobody is doing it because it's "icky".
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5116034/
Every surgical procedure carries a real risk, which amortizes over the population of billions of people into thousands to millions of complications and deaths. That's the cost, and an intervention has to be good enough to justify that cost. Vaccines are good enough for that. Some types of cancer screening is good enough for that. Popping yourself in a full-body scan for a fishing expedition? Almost certainly not.
The result of this product is that a few more very rich people will die a bit sooner than they would have otherwise. Whether or not you think that's an upside is up to you and your personal politics.
Am I not allowed to criticize decades of research on astrology because I haven’t paid any attention to it?
If 30 years of research and clinical debate have led to this situation where you get 5 different opinions from 5 different doctors, then maybe it’s time to kick out the incumbents and replace them with people who adhere a little better to the scientific method. I would rather trust my medical care to a group of particle physicists who had one year to study medicine than the 30 year experts who can’t reproduce any of each others’ work and seem ignorant of any advances in statistics or inference over the same period of time.
No, you get the same opinion from all five doctors. That the scan is unnecessary.
You're behind the times. Now it's Cologuard. Not invasive although it is gross.
It's the 16% false positive rate, which they helpfully do not provide a dramatic anecdote for, that should give you pause.
If you test everything at the same time, some values are bound to be outside of the normal range, just because you’re measuring so many things at once. Doing any kind of procedure to further investigate or treat the symptoms has a risk associated with it.
In the end, doing a full body scan, with current medical technology (both in terms of the test equipment as well as our means to treat anything that comes up as a result of the test) is a risky thing to do. It sounds nice in theory, but unfortunately we do not live in the utopia you speak of.
> Raise the price
Although raising a price does lower demand, a different price for a test doesn't make decision-making any easier. Predicting future costs and benefits (based on test results, not the test cost) is the hard part.
> a sign to improve medical research in that area
Decisions about whether to do a procedure assume current technology, not imagined future technology.
In non-utopian reality it'd be even worse, as the system would be optimized for shareholder value instead. Shareholders profit by scaring patients into believing they need to buy more medical interventions.
I think raising the price would just mean raised prices and effectively where we are now.
"Too many false positives leading to wasted time and costs? Raise the costs for the supplemental scans and improve detection precision and recall."
You can't improve precision/signal on an inherently weak and noisy signal. There are many things showing up on MRIs that currently require a biopsy. You need alternative DX routes to disambiguate, MRI alone can't do that. As for raising the costs - who pays? Medical costs are already completely bonkers.
"That’s a sign to improve medical research in that area. "
We know we need to improve search. We don't need to cause negative outcomes to reinforce that signal.
"Too much demand for MRI machines pulling away time from patients that need to use them? Build more MRI machines. "
Again, who pays?
"we should just plow ahead and address new problems as they arise."
There is the problem of opportunity cost. Is that the best possible way to spend sparse resources? The medical community currently mostly thinks that it isn't.
Targeting wealthy people first does solve the "who pays" problem. It might make the "too few researchers" issue worse. It will cause a lot of unnecessary biopsies (because often that's the only alternative dx route) - but you could certainly lean into informed consent there. You do run the risk of poisoning MRIs as a diagnostic tool, because media will report any inconvenience to sufficiently wealthy people as a major problem.
All of this might be solvable, but "let's just press ahead and see" is a very bad approach here.
A sufficiently-flexible & high-res set of downstream decisions can always choose to ignore data that isn't really helpful. Enough scans & experience might discover the new patterns.
Our ossified medical system, with those "already completely bonkers" costs, has a hard time adjusting, & sticks with habits & tech that's stale. Thus things the legacy system isn't ready to handle efficiently get blamed.
But the only way out is through. Letting those with discretionary funds try speculative things is a way to improve faster than waiting for a burnt-out & bureaucratically-deformed "medical community" to rustle up the will/resources.
So if we can't tell if it's malignant or not, you're saying we should start cancer treatment just in case? It's not a question of "tech that's stale" or "an ossified system" - it's a question of not being able to tell all malignant and benign cells apart until you look at them under a microscope.
The last thing that space needs is a bunch of uninformed tech folks going "I don't know, let the market solve it, tech is great". I really recommend getting at least a basic education on the subject.
But for most things, the advice would be: watch & maybe run some other tests, if cheap & low-risk, if and only if the preponderance of the data implies it's a net-gain.
If the MRIs become cheap enough, high-resolution enough, and the ML/stats-assisted classification becomes good enough – possible with more imaging/progression data – the most common thing might be: reimage in a month or two, compare results. Do more if and only if that calcs out for maximum welfare.
These are ultimately probabilistic equations, not things you can hand-wave off based on old anecdotes and mere hunches about what's net worthwhile, and what's not. You have to run the tests, run the numbers, and reach a data-driven answer.
On the other hand, people who don't trust the numbers, or their own ability to dispassionately follow the numbers if more data arrives, should absolutely be free to remain in blissful non-knowing.
Many people can – and many more with proper coachin should be able to – use new info only if it improves their welfare. They don't have to follow automated scripts from a less-informed era.
they don't require a biopsy; you're still free to not get the biopsy after the mri
sometimes getting the biopsy is actually worse for you, on average, than the small chance that you'll have a very rare disease. probably in those cases you shouldn't get the biopsy, which means the mri didn't actually help you, but it didn't hurt you much either; you're US$650 poorer and worried, that's all
in other cases getting the biopsy is better for you, in which case the mri did help you
> Is that the best possible way to spend [scarce] resources?
fortunately, we have private property, so we already have a system for allocating scarce resources: their owner decides how to spend them. this turns out to work much better than the alternatives that have been tried, which routinely result in famines and genocides. so we don't need to come to a global community-wide consensus on that question; instead we can consider each case as it comes up
Have you ever talked through a scan with an oncologist? Or are you just reasoning in the abstract because you feel you can first-principle it?
Also, seriously, you want to turn this into a communism debate? fwiw, capitalism has already decided. The vast majority of resources goes to anything but full-body scans, because actual experts made the call what's more effective. Repeatedly. On many cases.
But you are right, you are of course free to make bad decisions with your money, and there will always be somebody happy to separate fools from their money. Capitalism does work.
yes, earlier this year
also, fuck you
people like you are why i always regret succumbing to the temptation to participate here
If you scan any middle aged adult you will find abnormalities in their scan. In almost EVERY case those abnormalities will be benign, but once you've found them depending on risk factors a biopsy may be required. Almost all of those biopsies will also be negative, the tiny calcification in your lung or breast isn't a tumor. The swollen lymph node isn't a sign of lymphoma. A spot on a scan is FAR more likely to be down to habitus and scanning issues than some underlying medical issue.
But if you scan everyone, biopsy everyone, you're going to end up killing some of them too in addition to the waste of limited resources.
You’d see if any of those potential issues grew, or disappeared.
If you get the scan and do nothing, or you choose not to scan and do nothing, and it turns out to be something fatal, the outcome is the same: you die.
The difference, is if you do the scan, you might have an epiphany about your own mortality, and live your life truly savoring every moment, instead of being blindsided and quickly dying someday.
Too many false positives leading to wasted time and costs? Raise the price for the supplemental scans and improve detection precision and recall. Unnecessary procedures that make a benign situation worse? That’s a sign to improve medical research in that area. Too much demand for MRI machines pulling away time from patients that need to use them? Build more MRI machines. This is one of those situations where the ideal end goal seems obvious, and I think we should just plow ahead and address new problems as they arise. In the long run, better preventative medicine will save time, costs, and minimize suffering for everyone. A few road bumps along the way shouldn’t dissuade us from even getting started, otherwise we never will.